The Torn ACL Info for BJJ/MMA/Judo/Grapplers FAQ (ver 1.2)

By The Stewed Owl
(This is a FAQ that's a work in progress, since the topic of ACL injuries comes up so often on MMA.TV. I will refine it and add links when I have time, including the posted experiences of other MMA.TV members such as eabeam and tyrian. As there's no guarantee of a post being archived (a similar thread was deleted with a lot of good info), I'll keep this on my hard drive and if someone wants to see it in the future, post a thread to my attention or just post "Need ACL FAQ" or such.)
I had surgery for a torn ACL and torn meniscus in my left knee in November, 2000 (Election day - I drifted in and out of post-anaesthesia consciousness, as announcers said first Gore had won, then Bush, and I thought I was hallucinating it all). Since this topic comes up a lot, I'll post this, based on my own experiences. Thanks to everyone on this forum who gave me good advice and support before and after my surgery, it helped a lot.
I wish I had the surgery earlier, as I feel very strong in the affected leg now, and regret the loss in training time over 4 years before I had the surgery. I'm in my mid- forties, train in BJJ 4 - 5x week, and will probably never be the PRIDE or mundial champion but I compete (and sometimes win) in local BJJ tournaments as a hobby. I still enjoy it a lot and it makes my life a lot more fun and enjoyable.
MAKE SURE YOU READ THE FIRST QUESTION AND ANSWER.Q: Are you a doctor?
A: NO! Nor do I play one on TV! ANY medical advice given over the internet is suspect, so CHECK WITH YOUR DOCTOR AND PHYSICAL THERAPIST BEFORE FOLLOWING ANY OF THE ADVICE BELOW.
As doctors and physical therapists may not be familiar with our sport(s), I am including some guidelines based on my own experience with ACL reconstruction, the posted experiences and suggestions of other MMA.TV forum members, and some on-line resources for further self-education.
Q: I heard a POP! sound in my knee when rolling last night. It hurt quite a bit, so I iced it up and took some ibuprofen. It is still pretty swollen and painful. Should I go see a doctor?
A. Yes.
If you even THINK you may have injured your knee, do the RICE thing (Rest-Ice-Compression-Elevation) and see a doctor as soon as you can, especially if you hear a POP! sound during the injury.
REST = stay off the leg as much as possible until you can get to a doctor
ICE = apply an ice pack to the injured area
COMPRESSION = use an ace bandage to reduce swelling
ELEVATION = prop your leg up so your knee is above the level of your heart.
Taking some ibuprofen may also reduce swelling.

Q: What the hell is an ACL, anyway?
A: ACL = Anterior Cruciate Ligament. It is the ligament in the center of your knee, crucial for knee stability, which is often injured by a twist too far one way. Also often injured is the MCL, or Medial Cruciate Ligament, which is on the inside of your knee and is susceptible to blows from the side. The meniscus, the padding between the upper and lower parts of the knee, are often torn during an injury as well, either alone or in conjunction with an ACL or MCL tear.
Numerous athletes in MMA and BJJ have torn an ACL, including Tito Ortiz, Vitor Belfort, Ricco Rodriguez, Nino Schembri, Ken Shamrock, Javier Vasquez, Michael (Bolo) Jen, Dan Henderson (who tore his doing a victory jump off the ropes after a PRIDE win!)....more than I can list.
Knee injuries in general, and torn ACLs in particular, are common in Judo. As the saying goes, young judoka are tachi-waza (throwing) specialists, old judoka are ne-waza (matwork) specialists.
If you want to see specifically how I tore my ACL, look in Royce and Charles Gracie's book "Brazilian Jiu-Jitsu: Self Defense Techniques" on page 55, lower left hand corner. I was practicing a throw from a Rear Bear hug on a (much larger) partner, and tried to take it easy on him when throwing him across my hips. I held my legs like Royce says NOT to do in the book, and had the guy's full weight collapse across the side of my knee, buckling it inwards. Ouch.
Certain other BJJ moves, such as bicep crushes from spider guard, gogoplata, some rubber guard movements, trying to stay standing when a larger opponent jumps to your guard, etc., have been noted as having an increased risk of ACL damage.

Q: How should I find a good doctor?
A: Make sure that doctor is an orthopedic specialist (not a general practitioner), if at all possible. Try to find someone who specializes in sports medicine. TIP: look on the website of your local football or basketball team (NFL, Arena football, College, etc.) and see if they have a team doctor listed. Or call your local college or university coach and ask who they use. That's the doctor you want to use, if your insurance covers it - someone who's used to treating people in good shape who want to get back into athletics, is aggressive in prescribing physical therapy (PT), and who has lots of experience in treating knees. (Of course, if you have an HMO, you may have less choice in picking a specialist...)
As a general tip, start developing a range of medical specialists, especially if you continue to train as you get older. If you're not in an HMO, keep a photocopy of your doctor's names from your insurance company's preferred providers directory in your gym bag - I have an eye/ear/nose throat guy to drain my cauliflower ear, a general practitioner, a dentist if I chip a tooth, a orthopedic specialist for joints, a dermatologist for any weird fungi I could pick up off the mat...always try to go to a specialist.
Q: Do I need to get an MRI?
A: Whatever doctor you get, whether a general practitioner or orthopedic specialist, MAKE SURE YOU GET AN MRI, NOT JUST AN X-RAY! True Horror Story: I first tore my ACL in 1996 in grappling practice. The doctor I went to, who was supposed to be a good orthopedic specialist, only did an x-ray, and decided I had subluxed my patella (i.e., the kneecap had popped off track). I did physical therapy, it got a little better, but the knee was unstable for 4 freakin' years - every time I began to train seriously, I would tweak it getting down off a ladder or playing soccer with my son, and it set me back - that's 4 years where I was not able to train as effectively as I could have, if I had gotten a good diagnosis earlier. It kept feeling weaker and more unstable over the years, and I began having difficulty and pain when kneeling down or squatting to pick something up. A stable kneeling position when shooting on the range was almost impossible to attain. I finally went to a new orthopedic surgeon (the knee doctor for the Arizona Cardinals), who had an MRI done to confirm his first diagnosis: tear of the ACL, buckethead tear of the meniscus. The meniscus might have been torn over time due to the uneven stress of walking and running with a torn ACL. X-Rays DO need to be done before an MRI to see if a) there is a fracture, or b) a tumor, which in very, very rare cases can mimic a knee injury; but the x-ray won't show what's going on inside the soft tissues of the knee the way that an MRI will.
If it's a torn meniscus alone (and not the ACL), such injuries can often be treated arthroscopically and recovery time seems to be much faster.

Q: Can I get by with a brace and not get the surgery?
A: Some athletes decide not to get the surgery. Last I heard Ricco Rodriguez was fighting without his ACL (don't know if this is still correct), and Thurman Thomas played in the NFL for years without his ACLs. A store-bought neoprene brace does very little for you long term, however, in that it does not repair the long-term damage to the knee or protect against further injury. (see comments on derotational braces below) At best, it keeps the area warm and serves as a reminder to you that you have a bum knee and to protect it. If you do this, you may be trading short-term athletic success (or not...) for long-term physical disability. As one of the functions of the ACL is to stabilize the joint, the wobbly action of walking with a damaged ACL will gradually wear down the meniscus, which acts as padding for the knee and the between your upper and lower leg and contribute to osteo-arthritis of the knee in later years. Watch the way retired NFL players walk, and you'll see what I mean.
More importantly, the instability of your knee joint (remember, the ACL provides stability) will increase your likelihood of further, and more traumatic, injury the more involved you are in athletics. You may be able to increase stability in a knee with a torn ACL by building up the quads and hamstrings (a route I tried), but the very action of exercising (heavy deadlift and squats) can further damage a torn ACL.
Gordon Hester (a Rickson Gracie black belt) reported having torn his ACL two and a half years before the surgery, before re-injuring it again (presumably due to the weakened support frm the torn ACL). Against the advice from two doctors, he put off the surgery and decided to wait and train his legs harder to better support the knee. He was able to grapple and play tennis after the injury, but regretted putting off the surgery so long, feeling the first injury contributed to the second injury. I suspect that may have happened in my case too, as an attempt to hold up a much larger training partner who jumped to guard may have further injured or torn the ACL from the first injury.

Q: Can I avoid surgery through prolotherapy?
A. Get a second opinion, and talk with your doctor about alternative therapies if you're interested in those. Some ACL and meniscus injuries may not have to be treated with surgery, particularly if you are willing to transition to a less-active lifestyle (I'm not.) A friend at work tore his ACL - he is getting close to retirement, did not want to go through the hassle of surgery, and was willing (and ready) to transition to a less physical lifestyle, so he'll just wear a brace and forego the surgery (there is an increased risk of osteoarthritis the longer it's left untreated.) Some people on the forum suggested and have had good results with prolotherapy, an alternative medicine therapy.
The theory behind prolotherapy is that ligaments and tendons have a poor blood supply, which limits the amount of oxygen and nutrients that the blood stream can carry to injured ligaments, leading to partial healing and chronic re-injury. Prolotherapy seeks to increase inflammation of the injured area by injecting inert substances into the site and thus increasing blood supply and, the theory goes, increasing growth of new tissue rather than scar tissue. As the therapy is to CAUSE inflammation, no ice, anti-inflammatories, etc. are taken, and it is very painful for 3 - 5 days after the infection.
I didn't try it, but a couple of other people have said that it worked for them - talk to your doctor about it if interested. There was also a post (archived, I think) on the Strength and Conditioning forum by someone who did a review of medical studies in the journals on prolotherapy that seemed to show no verifiable results in reputable studies (i.e., double-blind, peer-reviewed research). See the original post on that, I have no experience in prolotherapy or other alternative medicine therapies and don't have the background to talk about that. If the ACL is completely torn, I doubt that any prolotherapy solution could cause it to re-attach.
Phil Cardella, an Austin-based BJJ instructor under Relson Gracie, reported good results from prolotherapy. MMA.TV forum members JRSFitness1 and DaisyCutter also have reported good results from Prolotherapy. Others have reported good results with shoulder, elbow injuries, etc.
Here is their website:
www.prolotherapy.com
Some insurance plans will not cover prolotherapy.

Q: What are my surgical options?
A. If you decide to go the surgery route, accept that you will be less mobile and active for awhile, but you will come back stronger if you commit to training consistently. I feel better now that I know what the injury is, its been corrected, and I can move on and get better.
Talk to your doctor about options, which are constantly improving, but surgery options include use of a piece of tendon from a cadaver; use of the middle third of of your patellar tendon (from just below the front of your knee); and use of a piece of your own hamstring.
There's a lot of discussion on whether to use a graft from the hamstring, the patellar tendon, or the ligament of a cadaver. The general consensus seems to be that you will recover faster with the hamstring graft than a patellar tendon graft, but that over the long term the tendon graft will be stronger and tighter (I opted for that). I've heard that a hamstring graft may be less painful to kneel on, but the pain hasn't been bad for me - mostly a little numbness when kneeling down with pressure directly on the knee. I don't have any problem sitting in seiza so my butt touches the mat. Synthetic grafts were tried back in the 1980s with poor long-term results.
Poobear posted that he got a hamstring replacement, then immediately got a hamstring tear that reduced his ability to walk and had to wear a brace for a year. A couple of other posters compared the faster recovery with the hamstring replacement, vs. better long-term stability and strength with the patellar tendon graft.
MakoJJ posted that he had the hamstring graft done and noted decreased recovery/rehab time for his hamstring graft, as the tendon graft requires the knee brace to make sure it takes and the rehab to rebuild flexibility into a tendon. With the hamstring ligament, MakoJJ did not have to wear a knee brace (only a neoprene sleeve to reduce swelling), was on crutches for only 4 days, and was on the bike in 2 weeks, the pool in 3, and jogging slowly at 4 weeks. His orthopod, the orthopedic surgeon for the San Antonio Spurs, told him the change in performance would be noticeable if he was an elite level powerlifter or sprinter, otherwise, there would be no noticeable difference.

On the other hand, Modern Samurai posted that after tearing his ACL (no meniscus damage) in a 1998 grappling tournament, he had a patellar tendon graft at the same time as a coworker tore his ACL in a softball game and got the hamstring graft. His post is worth quoting at length:
"This is what I can tell you: we were both on crutches the day after surgery. He was on the bike and stretching 2 days afterward. I was on the bike and stretching one week after the surgery. His condition improved very rapidly, much more so than mine. BUT!! At about the 2 month out point into the rehab, I was way ahead of him in every area. (We are both pretty muscular builds, and were both in good shape before injury, so prior conditioning or genetics were pretty much irrelevant). I was jogging and lightly rolling at about 4 months out, at 6 months post surgery the doctor gave me the okay to do whatever I wanted, and I started sparring and rolling again fairly hard with no problems. Oh, I never wore the stupid brace, either. They told me to try it, and use it if I thought it helped. I didn't feel it did, so they told me not to worry about it [I think he's referring to the de-rotational brace here, not the immobilization brace that is initially worn after a patellar tendon graft - Owl.] Here it is two years later. I do everything I ever did. Still a slight strength imbalance, but that is because a hectic schedule limits my home strength rehab more than I would like. My knee does make a bit of a "grinding" noise if I straighten it slowly, and aches a bit when it rains or is damp, but otherwise doesn't really bother me. My co-worker continues to have problems. Although he initially made quicker recovery to progress, he is right now about where I was at the six month of rehab, and still isn't confident enough to go back to sports. I feel bad for him. Just keep this in mind: Which ever way you go, which ever type of surgery you have, it is important that the doctor have done that type many times (highly experienced) and that you do your rehab like you're training for your next pro fight (even if you aren't a pro!) - Adam"
Bear in mind that my knowledge of ACL repair is circa 2000, and as I said, the procedure seems to improve rapidly.
For a good explanation of the surgery, go here

Q: What will the initial period after surgery be like?
A: Painful and uncomfortable.
Depending on your doctor, you may be using a polarcap knee icer, a continuous motion, and probably some pain-killing drugs in the early period of your recovery.
My doctor prescribed vicodin, which I took the first night to help sleep. I don't like the way drugs feel, and the pain was not especially bad for me, so I didn't take any after the first night.
The Polarcap is a small ice chest with a cooling unit, a pump and tubes that lead to a pad that fits around your knee. You fill it up with crushed ice and some water, and plug it in as you lay in bed or on the couch. It circulates ice water around the joint, reducing swelling. My wife took a couple of days off work to help out, then I was on my own while she was at work and the kids were at school. When the ice ran low, I would have to get up on my crutches, slide the cooler like a bowling ball into the kitchen, fill it with ice, then shove it back and hobble my way back to the couch.
More difficult to deal with was carrying something that required both hands while manipulating 2 crutches, like a plate of food. You soon realize you can either walk, or hold something, but not both at the same time. The worst was not being able to pick up my infant son and carry him.
Going up stairs was not bad, albeit slow, but going down the steep stairs in my house was scary... you have to be careful with your balance, once I leaned too far forward as I moved the crutches down, and almost pitched head forward down the stairs! I managed to catch myself by spastically throwing my crutches forward to break my fall, but I was concerned about the possibility of tearing the graft more than hitting my head!
You will be down to one crutch after a short period of time (2 weeks for me), and then things will get easier.

Q: Will I be able to drive?
A: If you hurt your left knee and you drive an automatic, you're in luck. Otherwise, you may have to get someone to drive you initially.
Q: Will I be able to, um, you know...
A: The missionary position, or others where you put your weight on your knees, may be uncomfortable for the first several months. Your partner will have to be on top, and that's all there is to it!
Q: What kind of rehab should I do?
A: Initially, your doctor will prescribe a series of exercises for you to do while recovering at home, in conjunction with prescribed exercises overseen by your physical therapist. He may also give you exercises to do in a commercial gym at the same time as you are training with the therapist. Eventually, you will transition to a gym-based program as you take more responsibility for your day-to-day rehab.
Explain to your therapist what you do in your sport, and that you are committed to returning to it. He will probably be pleasantly surprised to have someone who works hard to improve, as most of the people he sees are work-related injuries who come in to get off work, get a little ultrasound, and do the minimum possible. You might also see whether your plan covers an athletic trainer. A PT, as it was explained to me by forum member m.g., is only committed to returning your body to normal (non-athletic) function; an AT is supposed to get you back to your athletic peak.
The purpose of your rehab is to quickly regain range of motion (ROM) and strength and size in the leg. (You will be surprised how small your leg will look compared to the other after wearing an immobilizer brace.) You will later begin working to redevelop a limp-free walk and run, and to re-develop sports-specific skills.
Your doctor will prescribe walking, and eventually running on a treadmill. You will also probably do some resistance band work at your physical therapist, where you wear a harness hooked to a huge bungee cord and you run in place backwards, forwards, and sideways against the resistance of the bungee.
Some people (those lucky enough to live with access to a beach) have found that walking on wet sand provides gentle resistance, followed by icing the knee afterwards as required.
Side-to-side rehab training under your therapists's guidance will probably include some lateral-movement strength drills, such as use of a slideboard or those side-to-side skiing rockers.

I didn't get a chance to use a swimming pool much for rehab (it was winter when I had surgery) but once it warmed up I would walk around in circles in my pool, letting the water support most of my weight. As I got better, I would carefully practice kicking against the resistance of the water - knees and thai kicks, roundhouses, front thrust kicks, snap kicks. I would also hold on to the side of the pool and do flutter kicks, and gradually work up to swimming laps. Swimming is a great, low-impact way to strengthen your body and improve cardio.
Most important is to take it slow, don't risk re-injury. Start small, always trying bodyweight exercises before adding resistance. You have to walk a tight rope between aggressive rehab and re-injury, so get advice from your physical therapist and your doctor. When in doubt, err on the side of safety. You do NOT want to go through that surgery again!
Your doctor will prescribe a course of PT for you - some are more aggressive than others. Mine was aggressive on the rehab, but conservative on the time before I got back into my sport. You will have to work hard to a) get full ROM back and b) rebuild size and strength in the affected leg, which atrophies quickly after surgery and being in the immobilizer brace you will wear even after getting off the crutches. Surgery itself has a catabolic effect on your body, so be prepared to lose some lean body mass. The stationary bike worked well for getting ROM back for me, I would position the seat as low as I could stand (which at first was as high as I could get it), and SLOWLY pedal the bike, going forward and back, always working on getting the bikeseat lower in each session until I got the seat down real low and looked like a damn trained bear riding one of those little bikes around the Big Top. I think doing this regularly helped me regain ROM in the knee more than anything else.
Don't neglect your upperbody while you're rehabbing your knee. A day or two out of surgery, I started doing lots and lots of push-ups, once I figured out how to prop my injured leg with its immobilizer brace on top of the good right ankle, and did lots of crunches with my legs propped up on the couch. I did all kinds of push-up variations: diamond push-ups, grip wide, one hand forward and one back, one hand elevated, etc. If you are at all athletic, you will find that being able to do anything physical feels good while you are on crutches, both as a stress release and so you don't feel like an invalid. Like a prisoner restricted to one session of exercise a week, you begin to really look forward to it!
This is a good time to develop your grip - I invested in a pair of the Ironmind "Captains of Crush" grippers (www.ironmind.com) and used them religiously throughout my workout. The Ivanko Supergrippers are also great (available at www.fractionalplates.com/equipment/equipment23.html). Develop the Grip from Hell for when you come back on the mat!!!! (Also check out the IronMind book on developing grip strength - lots of good exercises and ideas!)

Once your doctor gives you the okay to begin doing your rehab in the gym, invest in a membership in a decent health club if you can for the wider range of equipment. Take the opportunity to hit upper body too, and make it a goal to improve your overall upper body LBM. Stack-loaded machines (as opposed to free weights) will be more convenient and safer to use during this time, as you don't want to be picking up and moving 45-lb plates around the gym with your injured knee, so swallow your pride and hit the Cybex, etc., machines. A simple upper body workout might include a bench-press machine, lat pull down, pull-over machine, pec deck, seated row, and bicep machine. Start slow and give your body time to adjust to a higher level of physical exertion after lessened activity. Nino Schembri tore his ACL, started hitting the weights for his upper body while doing physio, and bulked up to 85kg. Ask Sak about Nino's knee.
Once the immobilizer brace came off, my leg was a stick, very obviously smaller in size than the other one. Once your doctor clears you to do exercises, concentrate on regaining size in both the quads and hamstrings. Talk with your doctor to see what he recommends. My orthopod had me doing something for the legs everyday, but varying the rep scheme and exercises. (Similar to what Pavel Tsatsouline recommends in a lot of his exercise protocols, by the way). The variety seemed to help me come back, and my left leg is now the same size as my right.
I tried to emphasize the eccentric (lowering) movement in each of these exercises to help build mass.
Out of all the exercises below, I worked out a schedule where I would do 2 - 3 different quad exercises and 2 - 3 different hamstring exercises a day, rotating them day to day throughout the training week and varying resistance as the leg became stronger, either through adding weight or increasing stability demands (use of a Swiss Ball, unstable surface, etc.) as strength improved.

Some of the exercises that I used for my legs included:
o bodyweight squats (not going too far at first, about 1/4 of the way down)
o singleleg squats (using a jumprope or bungee cord tossed over a chin-up bar for support)
o leg presses (warming up with both legs, then single leg - pyramiding up in weight seemed to work), also doing assisted eccentric overloads on the leg press (heavy load for the bad leg, pressing it with both legs, then slowly lowering it with the weak leg - be very careful doing this)
o step-ups on a low bench (gradually adding weight by holding dumbbells)
o s-l-o-w-l-y walking up stairs and down at home, including side-stepping
o glute-ham raises with my ankles on a Swiss ball
o the multi-hip machine (very important for regaining stability and strength)
o side-to-side skating on a slideboard (very important for building lateral stability)
o static squats with my back against a wall for time, eventually resting my back against a Swiss ball to improve balance
o I worked up to barbell squats, just bodyweight at first and not going below parallel, very gradually adding weight and going deeper. I used a mirror to make sure that the bar remained level and that both knees were doing equal work.
o bodyweight lunges forward and back and side to side; sometimes moving the front leg forward, sometimes moving the rear leg back, and vice-verse for side lunges; as stability improves, gradually add weight by holding dumbbells in each hand or holding a medicine ball in front of the chest. Try not to let your knee move past your shin initially.
o Good Mornings concentrating on moving your hips back instead of dipping your body forward with very light weight on the barbell (the best hamstring exercise, in my opinion - when you do it right, you will feel the burn in your hams, just below your butt.)
o Standing, seated, and lying leg curl machines (having access to a big gym with a variety of machines helped)
o A "leg sled press" machine (a leg press machine where you rest your feet against a plate and the sled you're lying on moves, as opposed to a leg press where your body stays still and you move the plate with your foot) with single leg presses seemed to help a lot.
o Running in place forward, sidewards, and backwards against resistance from a big bungee cord attached to me by a climbing harness.
On all the single-leg variations of the above, I would warm up by doing a couple of sets with both legs, then just hit the weak leg. Eventually, I bought a mountain bike and began cautiously riding on low, level ground (the canal banks around Phoenix), and then added 5-lb ankle weights, taking it nice and slow. Quite a quad workout.

The elliptical trainer in my gym got a lot of use, too, as I would crank up the resistance as much as I could and do 3 minutes forward, pause, and then 2 minutes pedaling backwards, working up to 30 - 40 minutes.
I would also walk forward and backward at an incline on a treadmill.
I initially did squats (stopping well short of parallel) on the Smith machine, thinking this was safer but found that it was actually unsafe due to the lack of involvement by the hamstring as a stabilizer muscle and the increased shearing force on the knee (cf. Charles Poliquin); likewise with leg extensions, an exercise that uninformed physical trainers recommend to "strengthen the muscles around the knee" but which can increase shearing force on the knee.
Learn the difference between a closed chain and open chain exercise and select the former as much as possible (In a "closed chain" exercise, the bottom of your foot remains in contact with the ground or a plate - squats, deadlifts, leg presses. In an "open chain" exercise, it doesn't (leg extensions, leg curls).
TALK TO YOUR DOCTOR/PHYSICAL THERAPIST BEFORE DOING ANY OF THESE!!!!!
As maintenance now, I deadlift and squat, do Good Mornings (pushing my hips back) and leg curls for the hamstrings, and do one-legged squats (pistols). I'm trying to do more yoga (Power Yoga) when I have time.
Keep a daily log of your exercises, it will help give you motivation as you see your poundages, reps, mobility, and ROM improve.
Here's a good post from July, 2003, by Chris Savarese of Tribe Fightwear (www.tribefightwear.com, cool designs): "An ACL tear isn't the major deal it was 5 - 7 years ago. The medical field has improved 1000% on this injury in the last 3 years. About 2 years ago, I tore my ACL, PCL, and LCL in a tournament. I had reconstructive surgery. One of my worst memories was reading the newspaper and reading how Jamal Lewis of the Baltimore Ravens had just started running after his ACL surgery (he had gotten hurt 5 months before). I wanted to jump off a bridge. I figured, he is a professional athlete, has only one of the injuries I have, and he's just starting to run? But I didn't look back from there. I really believe the two most important things are 1) get in a really good rehab facility that is used to dealing with athletes and not old people and 2) always stay positive. You will have bad days in rehab. Put them away as soon as you get home. Some of my best gains in rehab came the next day after a bad one. You will be fine. My bad knee is stronger than my right one now. I might tap out faster to kneebars and heelhooks faster, but I don't care, I'm just happy to be back. I'm telling you, if you work hard in rehab, you'll be training normal in 8 - 9 months."

One thing you will find after tearing your ACL is you begin to read the injury lists in the sports section of the newspaper more closely. You will find ACL surgery is creating much less down time for athletes these days.
Stretching multiple times during the day (morning, during breaks at work, after work) was key. Even when sitting and watching the TV, I would rest my leg on a hassock and place an ankle weight on top of the knee to gradually stretch the knee out to full extension. I cut a chunk off one of those thick foam pool flotation noodles (or use a thick pillow bolster), rested my ankle on it and pushed down gently to get full extension as a floor exercise. A stretching rope was very helpful, although you could also use a towel or just get a thick rope, about 18' long, and tie loops in it along the length about every foot. I would lie on my back, hook my ankle through a loop, extend my leg up, and gradually pull my leg towards my head. More painfully, I would lie on my stomach, hook my ankle through a loop, and pull the rope over my head to pull the foot forward and stretch out the quad. Very painful but that stretch helped me a lot, duplicating the manual stretches done by the physical therapist. It was very difficult to sit on my knees in seiza, due to the pressure and lack of flexibility. So I would prop a big pillow under my butt and sit back for as long as I could, gradually decreasing the amount of padding under it, and keep some kind of padding under my knees for the pain where the tendon graft was. My employer was very good about giving me extra time during the day to work out, so I stretched 2 - 4 times during the work day. I still stretch every day now (much more so than before the injury), doing about 30 minutes a day while watching TV instead of sitting on the couch, working my knees ability to flex at extreme angles, and to hold and relax into the stretch. Tight hamstrings are a major contributing factor to an ACL tear, so I continue to work on that a lot. Get a good book on stretching (Bob Anderson's "Stretching" is the bible and still the best) and find LOTS of different stretches to do to hit your lower body from different angles. Find new stretches for the knees, hips, hamstrings, abs, calves. If I'm not walking, I'm usually stretching something.
Learn alternative ways to move that place less stress on the joints. I found ways to do a penetration step, low squat, etc. from Scott Sonnon's first tape in the "Grappler's Toolbox" that helped a lot. Frank Shamrock's "Ultimate Home Workout" tape also has some useful suggestions on modifying bodyweight workouts, shoots, etc., if you have bad knees. As strength and ROM improved, I added more exercises from Sonnon's tape that gave me more confidence in being able to move without risking re-injury. Very worthwhile tape to buy. I was very concerned about kicking when I trained stand-up, particularly Thai-style "te" roundhouse kicks, as I felt that the pivoting foot would be at great risk, whether I planted the support foot at an angle or pivoted on the balls of the support foot as I kick. I'm careful and haven't had any real problems, and work the heavy bag and thai pads pretty hard, but I'm less inclined to kick than punch now. I'm cautious in doing throws that require me to plant on one leg and pivot (like uchi-mata, which used to be my favorite and preferred throw) or harai-goshi. If you're a BJJ guy who wants to work on his throws, take some time with a high-level Judoka and work through some throws and variations that seem safe for you. It will be time well-spent.

Train with partners you trust and don't be afraid to tap quickly when starting out if you feel the knee is at risk. Don't let your ego get you hurt.
When you start rolling again, roll with people you trust when you start out, no new guys or spazzes. Make sure you tell them beforehand that your leg is injured, and not to use leg attacks. One training option you might consider is drilling moves in ultra-high reps. In Oldfox's post on training at Brazilian Top Team, he said Mario Sperry told jim he takes 4 techs a day and drills them with a partner about 100 times each before a class. That kind of implanting of a tech in your muscle memory may make you a far better player than just undirected sparring and would be a safer way of training while injured - obviously, don't drill techs that put your knee at risk.
Here is a rehab protocol - use as a guide, but go with what your doctor and therapist recommends. This will give you an idea what to expect:
"Anterior Cruciate Ligament Reconstruction" by Herbert A. Haupt. M.D.

Q: What is the recovery time before I can start training BJJ / MMA / Judo again?
A: Many doctors and physical therapists will be unfamiliar with the demands of our sports (it helps if you equate it to wrestling). Here are some experiences from forum members:
"Korhal", a physical therapist who posted on the forum, suggested:
o Rehab exercises only and walking x 6 months
o Light training drills with no full contact x3 months after that
o Hard training at the 10 month mark, but go easy on the free rolling and free sparring.
o 1 year, you're good to go.
The above schedule is basically what I did and seems a good, conservative (but not too conservative) timeline.
Korhal went on to say: "If you do it this way, you'll have a good knee for life. If you rush it, you'll be missing training sessions and icing your knee for life."
One of the risks of getting back into grappling too early, or pushing it too hard on running, etc., is the risk of tendonitis, especially if you got the patellar tendon graft. mrarmbar2you reported that he started jogging 3 - 6 miles 2 month after his graft, and felt that tendonitis resulted from over-use before his knees / quads were ready. I've heard of a couple of people who had this happen because they were pushing running as a method of rehab. I'm no longer a big-time runner, I prefer to get cardio on the mat or by doing low-impact (swimming, elliptical trainer, recumbent life-cycle). It's likely that some of the injury to my meniscus came from the running I did after I first injured by ACL. Also, be cautious running on the open road too early as hyperextension (as in stepping in a pothole or rut) is a good way to re-tear the graft. If you're going to run, do it on the treadmill. Some sort of running is probably essential in rehab to learn to walk and run without a limp or favoring one side.

MMA.TV FORUM MEMBER EXPERIENCES WITH DIFFERENT GRAFTS AND REHAB TIMES:
Rickson Gracie black belt Gordon Hester got a cadaver ligament repair in April 2003 and it was done arthroscopically vs. cutting open the entire knee. He reported that he regained ROM rapidly and was able to begin working out more quickly, reducing the amount of leg atrophy.
MMA.TV forum member voice13 reported getting a cadaver graft for a totally torn ACL in April, 2003 with no problems and rehab beginning two weeks after surgery.
MMA.TV forum member Tyrian got a cadaver ligament graft in November 2002, and was doing sprints, grappling, judo as of July 2003.
MMA.TV forum member WhiteWhale had a patellar tendon graft done in August, 2002, and as of July 2003 estimated his knee recovery at about 80%, with quad strength about 70%, and was wrestling and doing jiu-jitsu (both light) and was good with boxing.
MMA.TV forum member Joe Rogan (late of NewsRadio and host of NBC's "Fear Factor") reported that he had his left ACL done in 1993 with a patellar tendon graft, and it took a year before it felt good again. The doctor also left some meniscus tear that became a problem for years before Joe finally got it scoped. Joe said the rehab from the surgery was very painful. Circa March, 2003, Joe had his right ACL done with a cadaver graft, and said as of early July 2003 it felt great, with about 90% of his leg muscle back and 100% ROM and flexibility. He said he was ready to begin drilling and had been punching the bag and kicking it lightly for several weeks.
MMA.TV forum member eabeam reported in July, 2003 that 1 year and 3 months after ACL surgery he was competing in Muay Thai with no concerns about his knee. He said he did progressive PT from day one to 6 months, could train but not at 100% from 6 to 9 months, and from 9 months to a year, full out training. He makes the interesting point that "...not all the nerves heal full until one year -- so your "feel" and body awareness is pretty poor. This means the structure of the knee is safe, but you don't have the reflexes and responsiveness that you feel in the other knee.
MMA.TV forum member Reilly reported he tried ground work 3 weeks after surgery [!] but repeatedly hurt himself, spraining the knee several times and causing a lot of inflammation until he backed off training. He started lifting again at 4 months, which he felt was too soon, then again at 8 months, which worked out well but he jumped weight too fast. Reilly said at the one year mark his squat was at almost 70% of his pre-surgery lift and his leg press about 80%.
MMA.TV forum member noshame reported he had a complete knee reconstruction (ACL, PCL, LCL, scoped MCL, scoped lateral meniscus, bone fragments and nerve damage), and was back on the mats in about 4 months...but notes he didn't simply "return to training", but worked out with some guys he could trust and they drilled and did some EXTREMELY light sparring with noshame on his back only. He said it "probably wasn't the smartest thing to do, but again, it was very slow, safe, technical work. I just couldn't stay off the mats for the year they were recommending. I ended up going full at about 7 - 8 months."
Based on some of the above reports, if I re-injure my ACL (always a possibility) I would seriously consider a cadaver graft.

Tami Goldsmith, who trains in BJJ with Rickson Gracie, as well as other martial arts, wrote an article on the April, 1995 issue of "Inside Kung Fu" on her ACL injury and recovery ("Coming Back from Injury"). While lightly sparring with Rickson, she attempted a counter to throw but didn't bend her knees enough and heard a loud "pop" in her knee, then saw the knee immediately begin swelling with moderate pain. Tami thought she had torn the hamstring, and iced it. The pain and swelling continued after class, and she was almost unable to walk the next day. An MRI confirmed the diagnosis. Tami opted for the patellar tendon graft, feeling the longer recovery time was outweighed by the longer-term stability. After surgery, Tami began therapy after 2 days. Her doctor advised against martial arts training began a vigorous rehab schedule in hopes of returning back to training, relying to a great deal (as I did) on the stationary bicycle, having trouble initially in pedaling forwards. She asked Rickson to begin training her again one month after the surgery, which he finally consented to at the 2 month mark. They trained very slowly, working around the injured knee, even though she wore a custom brace to protect it. She continued to train in BJJ, avoiding any technique she did not feel safe in doing, using a brace and concentrating on upper body workouts. She also trained in Indonesian arts at the Inosanto Academy.
Her experiences are atypical, but it may be possible to train very lightly (without much sparring) if you are careful. I haven't heard her long-term results, so I would be VERY cautious about such an early return to training.
Q: Will supplements help?
A: Supplementation is controversial, but I wanted to give myself every advantage I could. I used Glucosamine Sulfate/MSM capsules, 500 mg taken 3x day (still taking those), and Knox Nutrajoint (which I took for awhile and stopped due to cost and awful gritty taste), fish oil capsules (Sam's Club's brand, very cheap, about 7 capsules each 3 times a day), and my normal vitamins and anti-oxidants (C, E, and NAC). I lost about 10 lbs after the surgery, mostly LBM, and used creatine which I felt helped regain LBM and strength. There are some valid scientific studies showing creatine helps restore lean body mass post-surgery. I gained 15 pounds back about 6 months post-surgery. Even when less mobile, I tried to eat clean and used MRPs as a supplement, and tried to avoid using sweets, pastries, beer, etc., as comfort foods during recovery..
Q: What will the scar look like?
A. Scarring, if that concerns you, was surprisingly minimal. A little over 1 year after surgery, you couldn't even tell I had the surgery unless you looked very closely. Your physical therapist will show you how to massage the scar (once it's closed up) to move and disperse scar tissue out. Surgery methods have improved, as friends with old (5 - 10 years ago) ACL surgery scars look like Dr. Frankenstein did the job. (And anyway, "Pain is temporary, glory is forever, chicks dig scars," as the t-shirt says.)

Update 8/2004 If you are concerned about scarring (and women who wear shorts or skirts may be), here are some suggestions:
o Protect new scars from sunlight, keep them covered or wear sunscreen. Scartissue also has less pigment than the rest of your skin, so they are more prone to sunburn.
o I did not use them, but I've read that anti-scarring lotions containing hyaluronic acid softens the skin and makes it more elastic during the healing process, reducing scar tissue formation. "Derma-E" makes such products.
o Curad has an over-the-counter product that has received some good reviews, Curad Scar Therapy Pads. These are breathable, flexible self-adhesive polyurethane pads that help flatten raised scars and give the scars a more natural appearance in terms of color and texture. They are reprotedly more comfortable than the old silicon gel sheets that used to be used for this purpose. You can put them on at night while you sleep. You can use them on scars on any part of the body, including the face, but don't help on acne scars. You have to use them for about 8 weeks before seeing results. Reviews show they can help even on decade-old scars. 1 box contains 21 pads, which is a 3-week supply. They can be purchased in major drug stores and supermarkets.
Again, I haven't tried these but they are supposed to be backed by good research. do a web search for the best price on-line.
Q: My doctor wants me to wear a de-rotational brace post ACL surgery. Is it worth it, can I get by with a store-bought knee-brace, and can I wear it while grappling?
A. My doctor wrote the prescription for a high-tech "Don-Joy" de-rotational brace which was fitted to me. It ran about a thousand dollars, of which I paid about $100 deductible, Blue Cross covered the rest. It is designed to prevent rotation of the knee and hyperextension . It is very sleek and lightweight, but there is no way I'd be able to wear the thing while grappling, it would tear my partner apart. It would be more useful if playing football, rugby, basketball, etc., or possibly while doing striking practice (boxing, muay thai, etc.) where there is a lot of pivoting and foot rotation. I think I wore it once or twice about 6 months post-surgery, while taking a FMA knife seminar where there was a lot of pivoting and side-to-side footwork, but I didn't feel it was really necessary, more a mental support than anything. It just sits it my closet now.
The Don-Joy website sells a padded covering for the brace if you want to try that:
Q: What are some good ways to occupy myself post recovery?
A: My physical therapist told me a lot of athletes completely drop their sport after an injury, as the feeling of loss of strength and mobility and fear of re-injury scares them. Keep up your interest in your sport and training during the post-surgery and rehab period: go to tournaments, watch fight and instructional tapes; research rehab and training methods on the internet; sit in on classes at your school, watch and take notes. That girl from Texas who won the Olympic high dive gold medal broke her ankle a couple of months before the Olympics, was unable to dive, and still came back and hit every dive perfectly. She mentally rehearsed every element of the dive over and over while in a cast. You can do the same. While rehabbing I would watch fight tapes, pause the VCR at a tie-up, then try to figure what move I would do if I was the guy on top or the guy on the bottom, and look for new moves in tournament tapes.
If you take notes after class, take this time to review them, find holes in your game, develop combos and transitions.
Read "It's Not About the Bike" by Lance Armstrong while you're recovering.

Don't torture yourself with thoughts about "If only I hadn't...." You think about all the training and tournaments you will miss, and how all your friends and training partners will be progressing so far ahead of you. Well, you can't travel backwards in time (if you can, please e-mail me), the injury happened, now you have to recover from it. Pirates Baseball pitcher Kris Benson, who talks about rehabbing his injured elbow on his website (link) wrote:
"As a pitcher, there are many things that you fear. You fear that game when you give up 5 runs in the first inning. You fear not being on the top of your game when your team really needs you to be. You fear giving up a home run to the opposing pitcher. (That's embarrassing!) But most of all you fear any type of physical problem pertaining to your arm. I had never experienced any serious problems, and I don't think I had ever been more scared than I was at this very time in my life. After being seen by a few doctors I knew that...surgery was inevitable. I knew that along with the pain of the surgery I would also have to endure a minimum of a 1-year rehabilitation program. That is the worst thing that can happen to a pitcher (other than having to have shoulder reconstructive surgery) and now I was being faced with it.
"It was funny how one minute I was sitting on top of the world and the next I wasn't even sure if I would be able to throw a baseball again. I spent the first few days after my surgery drowning in my own self-pity. I just kept having the thought of "what could have been" running through my head. Could this have been my breakthrough year? Would this have been the year I made the National League All-Star Team?...After about a week of this, I began to see that like any other hurdle I faced in baseball, there were a lot of positives to take from this experience. I would only end up finding out that this injury was going to end up teaching me one of the most valuable learning experiences of my life." (end quote)
Remember: the common man sees everything as a blessing or a curse. The warrior sees everything as a challenge.

Keep up your spirits post-surgery (its easy to get depressed and think you'll never be the same again). Rent inspirational sports videos and lots of action and comedy videos, listen to comedy CDs and tapes from the library (Chris Rock, Adam Sandler, Joe Rogan, anyone you find funny) and concentrate on staying optimistic and upbeat, it will help you recover physically faster (there is good research since the 1960s showing that watching/listening to humor speeds recovery from illness and injury, it improves your immune system).
The Stewed Owl's picks for best video rentals to watch in between rehab sessions:
COOL GUYS ON CRUTCHES MOVIES:
o Rear Window (dir: Alfred Hitchcock): Jimmy Stewart is laid up with his leg in a cast in girlfriend Grace Kelly's Apartment. To occupy his time when she is not home, he watches the neighbors of his apartment complex across the street with binoculars, getting to know them all, until he sees Perry Mason commit a murder. You will probably experience much the same thing.
o The Killer Elite (dir: Sam Peckinpah): Off-line CIA security specialist James Caan gets shot in the knee by back-stabbing partner Robert Duvall. Caan rehabs his knee, bags his nurse, trains in the martial arts, hooks up with uber-cool psychopath Bo Hopkins and Rocky Balboa's brother-in-law, and fights every martial artist who was working in Hollywood in the 1970s, all while wearing a knee brace. Excellent ninjas vs. automatic weapons ending.
o The Dead Zone (Dir: Robert Cronenberg): OG icon Christopher Walken wakes up from coma with psychic abilities, lurches around on crutches, bags his ex-girlfriend, kills Martin Sheen before he can become president and move into the West Wing. Tragic but cool movie.
o The Road Warrior. Mel Gibson hobbles through post-Apocalyptic Australia with a knee-brace. One of the few movies where a guy wears leather pants and still looks cool.
MAKE YOU LAUGH OUT LOUD MOVIES:
o Caddyshack
o Office Space
o Raising Arizona
o The Big Lebowski
GET-YOUR-SPIRITS-UP FLICKS:
o Remember the Titans
o The Program
o Visionquest
o Any Sean Connery James Bond
o Terminator 1 & 2
o Lethal Weapon (First use of Triangle Choke in a movie!)
o Dirty Harry
o Predator
o The Wind and the Lion (Find this movie and watch it!!!)
o Conan the Barbarian
o Enter the Dragon
o Aliens
o Reservoir Dogs
o The Rock
o Fight Club
o Tombstone
o Unforgiven
o Gladiator
o Pumping Iron
o Rocky 1, 2, 3
Use the surgery as a way to come back stronger and learn more about how your body functions.

Q: I haven't had an ACL tear. What can I do to avoid it?
A: Warm-up properly before training. Raise the body heat by light jogging around the mat, sports-specific drills, etc.
Good cardio conditioning (fatigue leads to careless playing and injury.)
The only thing more stupid than people who only train the top half of their body are people who only train the front half of their body. Every skeletal muscle has an opposing muscle. Together they move the attached bone(s) by contracting and expanding, (such as the bicep and tricep, guadricep and hamstring, etc.). More leg injuries are due to weak hamstring strength, vis a vis quadriceps strength, than any other cause.
Look at the number of exercises people do for the quads (squats, deadlifts, leg extensions, lunges, etc.) vs. exercises for the hamstrings (at most, a half-hearted set of leg curls). Exercises that develop the hamstrings (straight-legged dead-lifts, good-mornings with the hip thrust back, glute-ham extensions, etc.) and continuous proper flexibility training for the hamstrings will greatly reduce your risk of ACL injury, in my opinion.
Quad strength is apparently important, though. A summary of an article by Dr. M. Bodor (which I have not read) in the July, 2001 issue of the Journal of Orthopaedic Research found weak quadriceps muscles as a significant contributor to ACL injuries, stating "Strong quadriceps are important for ACL injury preservation and rehabilitation, and preservation of quadriceps strength is an important goal."
Running, the most common cardio cross-training activity, develops the quads more than the hamstrings, leading to an imbalance in one of the muscles groups moving your legs. Try jogging backwards. On a stair climber, exercise bike, or elliptical trainer, try going 3 minutes forward, then 3 minutes backwards.
As a general rule, if you are a big guy, running will take a toll on your knees. Cheap or worn-out shoes will exaggerate any inherent misalignment or instability in the knees. Go to a store that specializes in runners (not the local department store), and get a pair of shoes designed for your size and your gait. Orthotics may help. I had a podiatrist make a custom pair of orthotics insoles that were less comfortable and far more expensive than a pair with a hard arch support I bought for $20.00 a pair at the running-shoe store (I over pronate), but depending on your gait you may need custom orthotics.
Yoga programs that develop strength at extreme ROM, such as Ashtanga and Power Yoga, will also probably reduce your injury risk as well as helping your jiu-jitsu in other ways.
Don't wear spongy, air-cushioned running shoes for heavy lifting. Get a shoe with a firm sole for stability. You don't want to be wobbling around when doing a heavy deadlift or squat. (Pavel Tstasouline recommends old-school Converse sneakers)

Bicycling is GREAT for building up strength around the joint.
Balance training may help protect against ACL tears, although this is unproven. Various companies make wobble boards and such. A simple one can be made by buying a cheap vinyl play ball in a store, cutting it in half, then pouring cement in one of the ball-halves. Pop it out when dry, and you've got a half-sphere that you can practice balancing on with one leg, or make a pair for both legs. Jump USA sells Jumpsoles (those goofy-looking platform training shoes without a heel that Kramer wore on an episode of "Seinfeld"). They also sell Proprioceptor Plugs, little half-spheres that snap into the bottom of the jump sole to develop stability and strengthen knee and ankle joints - together, the soles and proprioceptor plugs and training video go for about $100. JumpUSA claims they reduce ACL injury risk from landing wrong from a lunge or jump (not contact injuries, such as a tackle), particularly as fatigue sets in during training or practice and the brains ability to recruit the proper muscle groups to keep you stable degrades. JumpUSA also sells other sports/rehab products, such as heavy-duty resistance tubing. The guys at www.onthemat.com like this product, and say that Frank Shamrock, BJ Penn, and Cameron Earle gave them the thumbs up.
Indo-boards, that look like a mini surfboard on a roller, are also popular for balance and coordination development, particularly if you like to surf, skateboard, snowboard, or wakeboard. They are available in several models from Renegade Training
If you are of the female persuasion, there is a body of research that shows you are at higher risk for an ACL tear (particularly as more women are physically active, and remain so later into life). Sports that require women to land and quickly pivot (such as basketball and volleyball) are seeing much higher rates of ACL injury. An NCAA study found 50% of women's knee injuries come from joint twists (pivoting on a fixed foot or changing direction while running) and joint hyperextension (jumping and landing with the knees straight).
There are a lot of exercise protocols for women to reduce the risk, including side-to-side shuffles, rapid foot movements, exercises that emphasize rapid changes in direction, and hamstring flexibility and strengthening. There are a lot of strengthening and movement-awareness training protocols developed for female athletes, but as training time is always at a premium, many coaches don't do them. They are on the internet, when my daughter gets old enough to train I'll make sure she does them if her school doesn't.

There are a lot of exercise protocols for women to reduce the risk, including side-to-side shuffles, rapid foot movements, exercises that emphasize rapid changes in direction, and hamstring flexibility and strengthening. There are a lot of strengthening and movement-awareness training protocols developed for female athletes, but as training time is always at a premium, many coaches don't do them. They are on the internet, when my daughter gets old enough to train I'll make sure she does them if her school doesn't.
Some ways to minimize ACL injury risk in "plant and pop" type injuries (for women, but men also) playing basketball, tennis, volleyball, etc.:
o In addition to strengthening the quads and hamstrings (backward runs, leg presses, squats, deads, hamstring curls, wall slides, lunges, etc.):
o Avoid flat-footed or stiff-legged landings - try to land bent-kneed on the balls of your feet, then rock back to midfoot.
o Keep a crouch stance, so your knees work as hinges and not ball-and-socket joints.
o Come to a stop with a couple of little steps, instead of one big plant
Q: Are squats, full squats especially, bad for the ACL?
A: Some trainers feel that full squats put excessive force on the ACL and can lead to a tear. Tom Incledon, writing in the www.testosterone.net on-line magazine, said :
"The (ACL) is put on "slack" when the knee is bent. The ACL is taut when the knee is in a fully extended position. The ACL is one of the strongest ligaments in the body and virtually impossible to tear when the knee is fully bent or without being exposed to some sort of trauma or excessive twisting/rotating movement. Squatting isn't trauma. Running, planting your foot, and then cutting to the opposite direction is trauma. Getting hit on the outside of your leg and having the leg rotate inward is trauma. Landing from a jump without having any muscular deceleration to break the fall is trauma. And getting hit in the knee with one of those old-time wrecking balls is trauma, but again, squatting isn't trauma."
I would think that going to a heels-touch-the-butt full squat could be dangerous if the squatter would lose control of the weight and torque the knees, though.

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